Finding into death of Travis Joseph Hartskeerl

Contributing factors

• Inadequate discharge planning from hospital to general practice
• Poor communication between Peninsula Health and Dr M.
• Lack of direct contact preparation with receiving GP prior to discharge
• Incomplete clinical records accessible to CLIPS clinicians
• Failure to recognize early warning signs of relapse (insomnia, paranoid delusions)
• Non-compliance with antipsychotic medication (depot injections)
• No follow-up by hospital after patient non-attendance at GP
• Lack of agreed action plan for managing non-compliance periods
• Absence of proactive communication with patient's primary carer (father)
• No transitional period or structured handover between hospital and GP care

Coroner's recommendations

1. Peninsula Health to ensure discharge planning explicitly provides for contingencies such as periods of non-compliance with medication, with agreed 'action plans' for all parties including the patient's primary carer and treating GP
2. Clear articulation and agreement of each party's roles and responsibilities when discharging patients to GP care
3. Ensure patients can easily 'return' to public mental health system when appropriate and GPs can facilitate such returns
4. Implementation of transitional approach to discharge planning with structured handover period rather than abrupt transfer of care
5. Proactive communication with receiving GP including direct contact to prepare and inform the practitioner assuming care
6. Training of CLIPS and psychiatric triage staff in risk assessment for clients with known mental health history and documented early warning signs
7. Improvement of access to complete clinical records and medication information for ED mental health clinicians
8. Implementation of protocols for contacting patient's primary carer when acute deterioration is reported